Cadaveric vs Silicone Simulator Training in Holmium Laser Enucleation of the Prostate: Master Class
By: Ahmed M. Mansour, MD, UT Health San Antonio, Texas; Fadi Alsayegh, MD, UT Health San Antonio, Texas; Lori Lerner, MD, VA Boston Healthcare System, Massachusetts; James E. Lingeman, MD, Indiana University School of Medicine, Indianapolis; Ahmed Ghazi, MD, MSc, University of Rochester, New York; Shannon Hall, MD, UT Health San Antonio, Texas | Posted on: 27 Jun 2023
Endoscopic enucleation of the prostate has been endorsed by guidelines as a size-independent option for the surgical management of benign prostatic hyperplasia (BPH). However, despite strong evidence in favor of holmium laser enucleation of the prostate (HoLEP) over other BPH treatment modalities, such as transurethral resection of the prostate and simple prostatectomy, HoLEP remains significantly underutilized. Reports from claim databases estimated that HoLEP accounts for less than 5% of all prostate surgeries performed annually in the United States.1 This scarcity, along with the perceived steep learning curve, impeded access for trainees to learn a much sought for procedure. Furthermore, other than the limited number of fellowships, there is a lack of standardized and applied training programs and models for urologists willing to learn HoLEP.
In response to this need, we organized the inaugural “Texas HoLEP Master Class” at UT Health San Antonio. A comprehensive curriculum was designed to provide trainees with the necessary knowledge to overcome the initial learning curve and gain access to the tools required to initiate an endoscopic enucleation of the prostate program. The hands-on part of the master class included training on fresh cadavers for the first time in the United States, as well as training on silicone simulation models.
Human cadavers have been shown to be an effective platform for skills training among different specialties, from basic skills to complex open and laparoscopic procedures.2 Their anatomical accuracy and similarity to live tissue allow the trainees to hone their skills in a safe setting without patient-related risks. However, cost, limited availability, and challenging logistics have limited their adoption in surgical training. Furthermore, little is known about the suitability of human cadavers as a training model for HoLEP. A recent European study performed on 2 cadavers demonstrated the validity of human cadaveric models for use in HoLEP training.3 To our knowledge, human cadavers were never used previously on a training scale for HoLEP in the United States.
Cadavers can be fresh, frozen, or embalmed. Embalmed cadavers have longer shelf life than fresh or frozen cadavers, making them a more sensible choice for training programs that need the cadavers for a long time.4 However, the embalming process alters the texture of the tissues and disrupts tissue planes; as such, fresh cadavers were used as our HoLEP training models.
Synthetic silicone and 3 D-printed simulators have been introduced as efficient models for surgical training and recently have undergone significant advances.5 They offer close resemblance to live tissue and help in the development of trainees’ spatial awareness in the early phases of training. Several silicone synthetic models are available for multiple procedures, including transurethral resection of the prostate and, more recently, HoLEP. They have been favored over virtual simulation machines, which currently do not deliver an equivalent experience to real tissue handling.
On January 27 and 28, 2023, the inaugural Texas HoLEP Master Class was organized at UT Health San Antonio. Forty-eight urologists registered—the group came from various practice settings and had different levels of experience. The master class was organized over 2 days; the first day included live surgery transmission of 2 HoLEP cases from the operating room, didactics covering all aspects of prostate enucleation, and a moderated panel covering tips and tricks of the procedure as well as management of complications. The second day was limited to 20 trainees. Each trainee practiced HoLEP on a synthetic silicone simulator, as well as on a fresh cadaver under faculty supervision (see Figure). A previously proposed 10-step technique for surgeons in training also was demonstrated.6
Executing a cadaveric HoLEP training workshop required close collaboration and communication among the organizing team members. Running 10 high-powered lasers at the same time required renting a special generator to ensure that the lasers were set up and operated safely and effectively. Adequate staffing was critical to ensure a constant supply of irrigation fluid and efficient disposal of drained fluid during the training sessions. Because the cadavers after HoLEP training were intact, they were utilized subsequently in other training workshops to minimize the cost.
Upon course completion, participants completed a questionnaire assessing their satisfaction of using the cadaveric models and compared it with their experience with the silicone simulators.
The majority of trainees agreed that compared with the synthetic silicone simulators, the cadaveric training models served as a more realistic representation of anatomy (95%). With regard to the steps of the procedure, most of the trainees believed the cadaveric models were superior to the simulators in realistic representation of bladder neck incision (91%), median lobe dissection (100%), development of the enucleation plane (100%), early sphincter release (95%), dissecting from 2-10 o’clock (100%), dissecting from 4-10 o’clock (95%), incision of the anterior commissure (100%), and final anterior dissection (100%). Trainees also agreed that tissue reaction to laser energy (91%) and surgical feedback (100%) were superior in the cadaveric models. When asked which training platform trainees would prefer to have access to in the future, 9.5% preferred both silicon simulators and cadavers, and 90.5% preferred cadavers only. Overall, the cadaveric models were perceived to be a better construct for teaching the HoLEP procedure.
This event demonstrated the feasibility, effectiveness, and sustainability of performing a hands-on training program that involves cadaveric training for HoLEP. In light of the positive feedback from attendees and faculty, the decision was made to hold the master class annually. Similar educational events are important to meet the needs of a growing number of urologists interested in learning HoLEP.
- Robles J, Pais V, Miller N. Mind the gaps: adoption and underutilization of holmium laser enucleation of the prostate in the United States from 2008 to 2014. J Endourol. 2020;34(7):770-776.
- Reznick RK, MacRae H. Teaching surgical skills—changes in the wind. N Engl J Med. 2006;355(25):2664-2669.
- Tunc L, Bozzini G, Scoffone CM, et al. Determination of face and content validity of cadaveric model for holmium anatomic endoscopic enucleation of the prostate training: an ESUT AEEP Group Study. Eur Urol Open Sci. 2021;32:28-34.
- Rajasekhar SSSN, Kumar V, Raveendranath V, et al. Advanced training in laparoscopic gastrointestinal surgical procedures using Genelyn®-embalmed human cadavers: a novel model. J Minim Access Surg. 2021;17(4):495-501.
- Ghazi A. A call for change. Can 3D printing replace cadavers for surgical training?. Urol Clin North Am. 2022;49(1):39-56.
- Gourley E, Hopson N, Elshabrawy A, Mansour AM. Thulium laser enucleation of the prostate: a standardized 10-step approach for surgeons-in-training. Urol Video J. 2020;8:100072.